Non-vasospasm complications of SAH

General medical complications

A nice review article is available to summarise of all the complications of subarachnoid haemorrhage. Particularly, Figure 1 represents the risk of complications as a percentage incidence. For instance, fever is present in up to 80% of SAH patients. The mortality from these various medical complications (like aspiration pneumonia, pulmonary oedema, renal failure, etc etc) among low-grade SAH is about the same as the mortality from the SAH itself.


The unsecured aneurysm will bleed again within the first 24 hours, and the second bleed is usually more severe. The rate of rebleeding within the first 24 hours is usually quoted as around 4-17%.

In view of this, the aneurysm should be dealt with as soon as is permitted by the neurosureon's availability.


This tends to occur after the first 24 hours. the cuase of hydrocephlus in this case is not the obstruction of the 4th ventricle, but rather a diffuse blockage of arachnoid granulations, preventing the resorption of CSF. Naturally, a sensible response to this would be to insert an EVD, and subsequently a VP shunt.


Oh's Intensive Care manual

Chapter   51   (pp. 568)  Acute  cerebrovascular  complications by Bernard  Riley  and  Thearina  de  Beer

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Connolly, E. Sander, et al. "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association." Stroke 43.6 (2012): 1711-1737.

Myburgh, J. A. "Triple h” therapy for aneurysmal subarachnoid haemorrhage: real therapy or chasing numbers." Crit Care Resusc 7.3 (2005): 206-212.

Bederson, Joshua B., et al. "Guidelines for the management of aneurysmal subarachnoid hemorrhage a statement for healthcare professionals from a special Writing Group of the Stroke Council, American Heart Association."Stroke 40.3 (2009): 994-1025.

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Marshall, Scott A., Paul Nyquist, and Wendy C. Ziai. "The role of transcranial Doppler ultrasonography in the diagnosis and management of vasospasm after aneurysmal subarachnoid hemorrhage." Neurosurgery Clinics of North America21.2 (2010): 291-303.

Greenberg, E. D., et al. "Diagnostic accuracy of CT angiography and CT perfusion for cerebral vasospasm: a meta-analysis." American Journal of Neuroradiology 31.10 (2010): 1853-1860.

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LITFL offer this reference as a follow-on to their chapter:

Dabus, Guilherme, and Raul G. Nogueira. "Current Options for the Management of Aneurysmal Subarachnoid Hemorrhage-Induced Cerebral Vasospasm: A Comprehensive Review of the Literature." Interventional Neurology 2.1 (2013): 30-51.

Frontera, Jennifer A., et al. "Defining Vasospasm After Subarachnoid Hemorrhage What Is the Most Clinically Relevant Definition?." Stroke 40.6 (2009): 1963-1968.

Vergouwen, Mervyn DI, et al. "Definition of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage as an Outcome Event in Clinical Trials and Observational Studies Proposal of a Multidisciplinary Research Group."Stroke 41.10 (2010): 2391-2395.

Etminan, Nima, et al. "Effect of pharmaceutical treatment on vasospasm, delayed cerebral ischemia, and clinical outcome in patients with aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis." Journal of Cerebral Blood Flow & Metabolism 31.6 (2011): 1443-1451.

Brathwaite, Shakira, and R. Loch Macdonald. "Current Management of Delayed Cerebral Ischemia: Update from Results of Recent Clinical Trials." Translational stroke research 5.2 (2014): 207-226.

Mir, D. I. A., et al. "CT Perfusion for detection of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis." American Journal of Neuroradiology 35.5 (2014): 866-871.

Lasner, Todd M., et al. "Cigarette smoking-induced increase in the risk of symptomatic vasospasm after aneurysmal subarachnoid hemorrhage." Journal of neurosurgery 87.3 (1997): 381-384.

Conway, James E., and Rafael J. Tamargo. "Cocaine use is an independent risk factor for cerebral vasospasm after aneurysmal subarachnoid hemorrhage."Stroke 32.10 (2001): 2338-2343.

Charpentier, Claire, et al. "Multivariate analysis of predictors of cerebral vasospasm occurrence after aneurysmal subarachnoid hemorrhage." Stroke30.7 (1999): 1402-1408.

Singhal, A. B., et al. "SSRI and statin use increases the risk for vasospasm after subarachnoid hemorrhage." Neurology 64.6 (2005): 1008-1013.

Yin, L., et al. "Predictors analysis of symptomatic cerebral vasospasm after subarachnoid hemorrhage." Early Brain Injury or Cerebral Vasospasm. Springer Vienna, 2011. 175-178.

Hussein, Haitham M., et al. "Intracranial Vascular Calcification is Protective from Vasospasm after Aneurysmal Subarachnoid Hemorrhage." Journal of Stroke and Cerebrovascular Diseases (2014).

Inagawa, T., K. Yahara, and N. Ohbayashi. "Risk Factors Associated with Cerebral Vasospasm following Aneurysmal Subarachnoid Hemorrhage."Neurologia medico-chirurgica (2014).

Inagawa, T., K. Yahara, and N. Ohbayashi. "Risk Factors Associated with Cerebral Vasospasm following Aneurysmal Subarachnoid Hemorrhage."Neurologia medico-chirurgica (2014).

Kolias, Angelos G., Jon Sen, and Antonio Belli. "Pathogenesis of cerebral vasospasm following aneurysmal subarachnoid hemorrhage: putative mechanisms and novel approaches." Journal of neuroscience research 87.1 (2009): 1-11.

Haley Jr, E. Clarke, Neal F. Kassell, and James C. Torner. "A randomized controlled trial of high-dose intravenous nicardipine in aneurysmal subarachnoid hemorrhage: a report of the Cooperative Aneurysm Study." Journal of neurosurgery 78.4 (1993): 537-547.

Rosenquist, Ashley, et al. "921: Safety of intrathecal nicardipine for vasospasm due to aneurysmal subarachnoid hemorrhage." Critical Care Medicine 41.12 (2013): A231.

Huang, Ren-qiang, et al. "Nicardipine in the treatment of aneurysmal subarachnoid haemorrhage: a meta-analysis of published data.Acta Neurologica Belgica 113.1 (2013): 3-6.

Kasuya, H. "Clinical trial of nicardipine prolonged-release implants for preventing cerebral vasospasm: multicenter cooperative study in Tokyo." Early Brain Injury or Cerebral Vasospasm. Springer Vienna, 2011. 165-167.

Pandey, Paritosh, et al. "A Simplified Method for Administration of Intra-Arterial Nicardipine for Vasospasm With Cervical Catheter Infusion." Neurosurgery 71 (2012): ons77-ons85.

Tagami, Takashi, et al. "Effect of Triple-H Prophylaxis on Global End-Diastolic Volume and Clinical Outcomes in Patients with Aneurysmal Subarachnoid Hemorrhage." Neurocritical care (2014): 1-8.

Dankbaar, Jan W., et al. "Effect of different components of triple-H therapy on cerebral perfusion in patients with aneurysmal subarachnoid haemorrhage: a systematic review." Crit Care 14.1 (2010): R23.

Lennihan, Laura, et al. "Effect of Hypervolemic Therapy on Cerebral Blood Flow After Subarachnoid Hemorrhage A Randomized Controlled Trial." Stroke 31.2 (2000): 383-391.

Diringer, Michael N., et al. "Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society's Multidisciplinary Consensus Conference." Neurocritical care 15.2 (2011): 211-240.

Velly, Lionel J., et al. "Anaesthetic and ICU management of aneurysmal subarachnoid haemorrhage: A survey of European practice." European journal of anaesthesiology (2014).

Kimball, Matthew M., Gregory J. Velat, and Brian L. Hoh. "Critical care guidelines on the endovascular management of cerebral vasospasm." Neurocritical care 15.2 (2011): 336-341.

Kirkpatrick, Peter J., et al. "Simvastatin in aneurysmal subarachnoid haemorrhage (STASH): a multicentre randomised phase 3 trial." The Lancet Neurology (2014), Volume 13, Issue 7, Pages 666 - 675

Mees, Sanne M. Dorhout, et al. "Magnesium for aneurysmal subarachnoid haemorrhage (MASH-2): a randomised placebo-controlled trial." The Lancet 380.9836 (2012): 44-49.

Nishiguchi, Mitsuhisa, et al. "Effect of vasodilation by milrinone, a phosphodiesterase III inhibitor, on vasospastic arteries after a subarachnoid hemorrhage in vitro and in vivo: effectiveness of cisternal injection of milrinone." Neurosurgery 66.1 (2010): 158-164.

Anand, Saurabh, Gaurav Goel, and Vipul Gupta. "Continuous intra-arterial dilatation with nimodipine and milrinone for refractory cerebral vasospasm." Journal of neurosurgical anesthesiology 26.1 (2014): 92-93.

Wartenberg, Katja Eliriede, and Stephan A. Mayer. "Intracerebral hemorrhage."The Stroke Book (2013): 204.

Wartenberg, Katja E., et al. "Impact of medical complications on outcome after subarachnoid hemorrhage*." Critical care medicine 34.3 (2006): 617-623.